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PREMENSTRUAL SYNDROME
by Peter Deadman
WESTERN MEDICINE
Definition
The occurrence of premenstrual physical and psychological changes
was first mentioned in the writings of Hippocrates1, whilst
premenstrual syndrome itself was identified in the 1930's by
Frank2,3.
Premenstrual syndrome (PMS) is defined as "a collection of differing
signs and symptoms which occur only in the premenstruum, i.e. after
ovulation, and is relieved by menstruation4". Symptoms may
therefore occur any time between 1 and 14 days (usually 7-10)
before menstruation begins, and remit after the onset of bleeding5.
The combination of symptoms seen in PMS occurs regularly, either
every month or most months, although their severity may vary
considerably from one cycle to the next. It is generally accepted that
PMS gets worse with age (worst between the ages of 30-40)6, and
usually does not improve after childbirth.
Symptoms
Although as many as 150 individual premenstrual symptoms have
been noted, the most common symptoms can be put into four main
groups:
Anxiety, irritability, mood swings and nervous tension.
Depression, insomnia, lethargy and confusion.
Bloating, weight gain, headaches and breast tenderness.
Increase in appetite, cravings for sugar and/or salt and fatigue.
Other often-reported symptoms include unease, insomnia,
sleepiness, aggressiveness, crying spells, clumsiness, poor coordination, difficulty in concentrating, decrease or increase in libido,
swelling, puffiness of the abdomen, face or fingers, weight gain,
constipation, diarrhoea, acne and skin rashes, muscle aches and
pains, and exacerbation of epilepsy, migraine, asthma, rhinitis or
urticaria.
Incidence
Depending on how it is assessed, between 5% and 97% of women
have been reported as suffering from PMS! More accurate estimates
point to around 35% of women having moderate to severe symptoms
which disrupt social life, work and family life and may cause a woman
to seek treatment, whilst 5-10% will experience severely debilitating
symptoms causing major disruption in all aspects of life7. As a result
of these figures, PMS has been described as the world's commonest
disease. PMS has variously been reported to result in increased
psychiatric admissions, suicides, alcohol abuse, child abuse,
accidents, accidents to children, examination failures, cardiac failure,
varicose veins, glaucoma and hospital admissions in general. It has
even served as a defence in murder cases.
PMS is not usually seen in the absence of other menstrual symptoms.
One study showed that while 15% of women suffered premenstrual
distress only, and 9% distress during the menstrual flow only, 58%
reported distress during both phases8.
Aetiology
The cause of PMS has resulted in much debate, contradiction and
confusion. This is in part because both physical and psychological
factors have been found to be both precipitating factors and
symptoms. As a result, there is dispute over whether PMS has a
biological or a psychological cause. Reported precipitating causes of
PMS include a past history or family history of depression, mental
illness or alcoholism, past history of sexual abuse, discontinuation of
the oral contraceptive pill, bilateral tubal ligation and hysterectomy.
An extraordinary number of possible aetiologies has been advanced
for PMS. These include progesterone deficiency, a fault in
progesterone receptors, oestrogen-progesterone imbalance, fluid
retention due to raised aldosterone levels in the luteal phase,
deficiency of vitamin B6, hypoglycaemia, and psychosocial and
personality factors. None of these theories is generally accepted as
having been substantiated.
Cultural factors
One part of the discussion around PMS centres on the way it is
frequently defined not by women, but by men, and how because of
difficulty accepting female assertiveness and anger, premenstrual
changes are generally defined as a (medical problem requiring
treatment. "The symptoms of PMT which the doctors show most
concern over - depression, anxiety and so on - are mental states
which do not 'fit' with women's culturally-created notions of ourselves
as nice, kind, gentle etc. 'Mood change' as such, is often listed as a
symptom - demonstrating that change as such is not culturally
unlimited supply of fuel, and giving vent to rage and anger will not
only fail to dispel the fire but will continually stoke and encourage it.
At the same time, the anger itself will injure the body, and at this
stage assistance is needed to help a person moderate excessive
emotion.
One other important aspect of the premenstrual waxing of Liver qi
needs to be mentioned. For some women, in whom there is relatively
little constraint, the days preceding menstruation occasion a welcome
feeling of greater assertiveness, decisiveness, clarity and creativity.
Even when there is stagnation that bursts out premenstrually, it may
mean that what needs to be said is said, and what needs to be done
is done.
Liver blood and yin xu
"The Liver is yin in its substance and yang in its function24". Whilst
this statement may be said to apply to all the zangfu, it is especially
important in relation to the Liver. The Liver is known as the
'indomitable zang' and corresponds to the energies of Spring, growth
and forcefulness. Although the Liver's free-going function assists the
ascent and descent of the qi of all the zangfu, its own qi direction is
upwards, hence the saying "The Liver governs uprising". Since its
growing, spreading and rising yang activity is by nature exuberant,
fierce and strong, the Liver yin and blood must be equally strong to
restrain and lubricate the potential harshness of the Liver qi. Blood
and yin deficiency can therefore lead both to a failure of the
freegoing function of the Liver and to excessive uprising of Liver
yang. Because of menstruation, women are prone to blood deficiency,
and PMS as well as many other gynaecological disorders, is often
characterised by the combination of Liver qi stagnation and blood xu.
In just the same way, the decline of Kidney yin as women approach
menopause*, may result in malnourishment of Liver yin and a
greater tendency to Liver stagnation. As far as treatment is
concerned we can almost generalise to the extent of saying that in
cases of Liver qi stagnation in women, the Liver blood or yin must
always be nourished.
Spleen disharmony
The nature of the Liver is to spread and extend, and this assertive
and outgoing quality can easily become aggressive when the Liver is
shi. At the same time, the Spleen, ceaselessly expending its qi in
transportation and transformation, easily becomes weakened and
exhausted and thus unable to resist encroachment by the Liver. The
pattern known as Liver-Spleen disharmony which is almost invariably
Acne
If Liver fire transmits to the Stomach and/or Lung it can manifest as
outbreaks of premenstrual facial acne. The key symptom that
distinguishes between the two is the presence of constipation
(Stomach). Two other pathological mechanisms may be involved.
One is the tendency of heat to separate off and rise (to the face)
when yin accumulates below, and the second is the resonance
between blood stasis in the lower jiao and the acne lesions
themselves, indicated by their purple coloration.
Non Liver patterns
Although Liver qi stagnation is the primary pattern seen in PMS,
there is another important mechanism for disharmony at this time.
As menstruation approaches, blood gathers in the Ren and Chong Mai
and if there is an overall body pattern of blood xu, it is likely to
become more pronounced at this time. Since the most common
precondition for blood xu is Spleen qi deficiency, the combined
pattern of qi and blood deficiency may be encountered. The blood xu
fails to nourish the Heart (giving rise to anxiety, palpitations,
insomnia etc.) and Liver (giving rise to dull lingering headaches, body
aches etc.), whilst the qi xu gives rise to general fatigue, lassitude
and possibly oedema. In women approaching menopause, as well as
younger women who are constitutionally Kidney xu, a similar
mechanism (gathering of blood and yin prior to menstruation) may
give rise to exacerbation of symptoms of yin xu and empty heat. In
such cases there may be little sign of Liver stagnation.
PATTERNS OF PREMENSTRUAL SYNDROME
Liver qi stagnation
Depression, weepiness
Irritability, frustration
Experienced positively as greater assertiveness, creativity and
clarity, less passivity
Distention, swelling or pain in the breasts and/or nipples, with
dislike of touch and pressure; in severe cases may begin around
ovulation or even persist through most of the menstrual cycle
Breast distention may be accompanied by lumps or nodules which
disappear soon after onset of menstruation or enlarge and reduce
according to the menstrual cycle; the more pronounced the swelling
According to symptoms
Depression and weeping: Tongli HE-5, Shenmen HE-7, Xinshu BL15, Tianfu LU-3
Irritability: Quze P-3
Breast pain: Shanzhong REN-17, Rugen ST-18, Qimen LIV-14,
Liangqiu ST-34, Jianjing GB-21
Headache: according to location, probably shaoyang channel
hence Taiyang (Extra), Shuaigu GB-8, Waiguan SJ-5, Yangfu GB-38
Stiff neck: Fengchi GB-20, Jianjing GB-21, Xuanzhong GB-39
Lower abdominal distention: Qihai REN-6
Irregular menstruation: Daimai GB-26, Xuehai SP-10, Ligou LIV-5
Dream-disturbed sleep, insomnia: Shenmen HE-7, Lidui ST-45, Yinbai
SP-1, Xinshu BL-15, Wangu GB-12
Constipation: Zhigou SJ-6, Daheng SP-15
2. Liver qi stagnation transforms to fire
In addition to the points listed for Liver qi stagnation:
Xingjian LIV-2: the Great Compendium of Acupuncture and
Moxibustion says "When the Liver is shi, drain Xingjian LIV-2" whilst
according to the Classic of Difficulties33 ying-spring points are
indicated for "heat in the body". Xingjian LIV-2, the ying-spring and
fire point of the Liver channel, is therefore the principal acupuncture
point to clear Liver fire and descend Liver yang.
Laogong P-8: the ying-spring and fire point of the Pericardium
channel is a powerful point to clear heat from the Heart. Due to the
close relationship of the Pericardium and Liver jueyin channels,
Laogong P-8 is particularly indicated when stagnant Liver fire
transmits to the Heart giving rise to various manifestations such as
susceptibility to anger, sadness, apprehension, restless zang
disorder34, mania-depression disorder, and burning sensation and
pain in the region of the Heart in women.
Tianfu LU-3: this point, which is rarely used nowadays, was
traditionally indicated for Liver fire which attacks the Lungs ("sudden
and severe thirst, internal rebellion, Liver and Lung struggle against
each other"35) as well as for a variety of psycho-emotional disorders
such as somnolence, insomnia, sadness, weeping, disorientation and
forgetfulness.
Yongquan KID-1: this is an important point to root excessive yang
and fire which rushes upwards giving rise to such symptoms as
dizziness, vertex headache, agitation, insomnia, poor memory, rage
with desire to kill people, depression with disordered speech, and
constipation.
3. Liver qi stagnation complicated by Kidney yin xu
In addition to the points listed for Liver qi stagnation:
Taixi KID-3 and Shenshu BL-23: as the shu-stream/yuan-source
and back-shu points of the Kidneys respectively, these are the two
principal points to tonify all deficiency patterns of the Kidneys.
In case of hot flushes and night sweats, add Rangu KID-2, Fuliu
KID-7 and Yinxi HE-6.
4. Liver and Stomach stagnant fire
In addition to the general points listed for Liver qi stagnation, the
points given above for breast distention and pain should be used.
Especially important are:
Liangqiu ST-34: as the xi-cleft point of the Stomach channel which
governs the breast, this point is indicated for all acute and severe
breast disorders.
Daling P-7: as stated above, the Pericardium jueyin channel has a
close relationship with the Liver jueyin channel, as well as with the
Stomach channel (the Pericardium primary channel passes through
the middle jiao). In addition to treating breast pain and abscess, this
heat-clearing point is indicated for insomnia, restlessness, anxiety
with a hungry sensation, weeping, fullness of the chest, chest and
flank pain, sighing and foul breath.
5. Liver qi stagnation accompanied by blood xu
In addition to the points listed for Liver qi stagnation:
Geshu BL-17: as the hui-meeting point for blood, this is an
important point to treat all blood disharmony, including blood
deficiency.
Zusanli ST-36: "The Stomach is the sea of qi and blood "36. As the
he-sea point of the Stomach channel, this is the most important point
on the channel to tonify both blood and qi.
Pishu BL-20: As the back-shu point of the Spleen zang, where the
qi of the Spleen emanates from the interior to the body surface, this
point has a strong action on regulating and tonifying the Spleen, and
thus promoting blood formation.
6. Heart and Liver fire stagnation, phlegm obscures the clear orifices
In addition to the points listed for Liver qi stagnation and Liver fire:
Fenglong ST-40: "The Spleen is the origin of phlegm"37. According
Sources
1. The most thorough source on Chinese medicine patterns involved
in PMS is My Sister the Moon by Bob Flaws, Blue Poppy Press, 1992,
and I am indebted to this book in helping to disentangle the
complexity of PMS patterns. Although mostly devoted to herbal
medicine, there are brief lists of acupuncture points for many of the
menstrual conditions discussed.
2. For a thorough discussion of PMS and Chinese medicine, see also
PMS. Its Cause, Diagnosis & Treatment According to Traditional
Chinese Medicine, also by Bob Flaws, Blue Poppy Press.
3. For a discussion of the dietary approach to PMS, see for example
Beat PMT Through Diet, by Maryon Stewart, Ebury Press. This is the
PMT Advisory Service Programme.
4. A book I found interesting and valuable is Menstrual Disorders by
Annette and Graham Scambler, publsihed by Tavistock/Routledge,
1993.
5. Personal communication with Steve Clavey and Mazin Al-Khafaji.
References
1 Ricci, J. The Genealogy of Gynaecology, Philadelphia: Blakiston.
2 Frank, R. "The Hormonal Causes of Premenstrual Tension", Archives
or Neurology and Psychology. 26:1053-7.
3 Due to a lack of source material, I am unable to give an overview
of historical perspectives on premenstrual symptoms in Chinese
medicine. Bob Flaws in My Sister the Moon, however, refers to the
18th century text The Golden Mirror of Medicine which gives a variety
of jing xing(i.e. menstrual movement) disorders which can occur
before or during menstruation.
4 Elder, M. (ed.) (1988) Reproduction, Obstetrics and Gynaecology,
London: Heinemann.
5 Whilst this is usually the case and indeed some authorities insist
that disappearance of symptoms immediately on onset of
menstruation is a deciding factor in diagnosing PMS, in fact the
symptoms may linger for a day or two, and in some cases persist
through several menstrual days. All authorities, however, agree that
a diagnosis of PMS requires the presence of s symptom-free week
after menstruation.